Be a part of a world-class academic healthcare system at UChicago Medicine as a Clinical Documentation Specialist for the Medical Records department at our main medical campus. The Clinical Documentation Specialist is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis.
In this role, the Clinical Documentation Specialist promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients' severity of illness. The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.
Essential Job Functions
- Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA.
- Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-9 CM Official Guidelines for Coding and Reporting.
- Consistently meets established productivity targets for record review.
- In collaboration with physician leadership, designs and implements specific tools to support physician documentation requirements.
- Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors. Discusses patient and hospital information only among appropriate personnel in private and appropriate settings.
- Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
- 5-8 years experience in Case Management or Med/Surg or Critical Care nursing experience
- Master's Degree
- CCS coding credential
- Analytic skills necessary to clinically assess medical records
- Bachelor's Degree
- IL RN License
- Basic computer skills in word processing and spreadsheet utilization
- Excellent interpersonal skills necessary to develop and foster effective physician communication
- Job Type/FTE: Full Time (1.0 FTE)
- Shift: Days – 8 hour shift
- Unit/Department: Medical Records
- CBA Code: Non-Union
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